Endoscopic laser treatment for tracheal obstruction

OBJECTIVE

To evaluate the efficacy of endoscopic laser treatment (ELT) in patients with endoluminal tracheal obstruction.

METHOD

A neodymium: yttrium aluminium, garnet (Nd:YAG) laser was used on 60 patients with significant (> 50%) tracheal stenosis. They were grouped as follows: primary tracheal malignancy (PTM n = 11), secondary tracheal malignancy (STM n = 27), benign tracheal tumours (BTT n = 4) and inflammatory tracheal stenosis (ITS n = 18). Assessment was made clinically, endoscopically and using ventilatory function tests (forced vital capacity (FVC) and peak expiratory flow rate (PEFR)), before and after treatment.

RESULTS

There was no treatment-related mortality. Peak expiratory flow rate improved significantly overall and in the PTM, STM and ITS groups. There was no significant improvement in FVC overall or in any of the individual groups. Subjectively, 98% of the patients felt improved by ELT. The survival in each group was: in the PTM group three patients are alive at 36, 49 and 74 months while all other patients died, giving a mean survival of 8.8 +/- 2.6 months. In the STM group the mean survival was 4.7 +/- 4.2 months. In the BTT group all patients are alive at the time of writing, two require regular ELT. In the ITS group three patients died, two required Montgomery tracheostomy tubes for tracheomalacia, seven are receiving regular ELT and six are disease free at the time of writing.

CONCLUSION

We conclude that ELT is an effective method for the palliation of malignancy which occasionally gives long-term survival. It has a place in the management of benign tracheal neoplasia and inflammatory stenosis with a potential for cure in these cases.

Spontaneous haemopneumothorax: a surgical emergency

We describe two cases of spontaneous haemopneumothorax treated successfully at emergency thoracotomy. We emphasize the importance of torn apical vascular adhesions as a source of intrathoracic haemorrhage in these two cases.

Spontaneous haemopneumothorax: a surgical emergency

We describe two cases of spontaneous haemopneumothorax treated successfully at emergency thoracotomy. We emphasize the importance of torn apical vascular adhesions as a source of intrathoracic haemorrhage in these two cases.

Thoracoscopic use of laser in intractable pneumothorax

A neodymium:yttrium, aluminum, garnet (Nd:YAG) laser was used via the instrumentation port of a standard thoracoscope for the sealing of air leaks, ablation of bullae, transection of adhesions and partial parietal pleurectomy in 13 patients with intractable pneumothorax. The mean duration of tube thoracostomy prior to treatment was 10 days (range 4 to 21 days). All patients had intractable air leakage. Three patients had chronic lung collapse of over 50% despite adequate chest drainage. All cases were treated with thoracoscopic laser. The source of air leakage was found to be ruptured bullae in 11 cases and a lung tear in 2 cases. In five cases the bullae were multiple. In 11 cases the air leakage stopped within 24 h of treatment, with a single self-limiting episode of recurrent air leakage. In two of the cases of chronic pneumothorax the lung failed to expand because of sizable bronchopleural fistulae. They required thoracotomy stapling of bullae and limited thoracoplasty. The mean duration of tube thoracostomy after thoracoscopic laser in the 11 successfully treated patients was 2.72 days (range 1 to 5 days). We conclude laser-assisted thoracoscopy is a useful therapeutic option when treating persistent air leakage. In most cases this method prevents prolonged periods of tube thoracostomy and obviates thoracotomy. In cases of chronic collapse of the lung with bronchopleural fistulae this technique may not be successful.

Management of unresectable oesophageal cancer: a review of 537 patients

We compared and contrasted the potentials of palliation afforded by various management methods in a retrospective study of all patients referred to one surgical team in a 20-year period. Five hundred thirty-seven patients had unresectable oesophageal cancer. There were five treatment groups: group 1-dilatation plus external radiotherapy (DXR, n = 95), group 2-gastrostomy plus DXR (n = 18), group 3-permanent intubation (n = 329), group 4-oesophageal bypass (BP, n = 70), and group 5-YAG laser plus brachytherapy (n = 25). Groups 1 and 2 had high mortality (4% and 25%) and poor symptom relief, with an average survival of 2.5 and 3.5 months, respectively. Group 3 had a 20% mortality rate, moderate-to-good symptom relief and an average survival of 4.2 months. This method was best for lower oesophageal cancer. Group 4 had a 22% mortality rate, good symptom relief and an average survival of 10.5 months. The BP method was suitable for patients with oesophago-airway fistula (OAF) and those with lower oesophageal cancer found unresectable at operation. Group 5 had a hospital mortality rate of 8%, good symptom control and an average survival of 6.2 months. This was suitable for all patients (except those with OAF). In palliation of carcinoma of the oesophagus the selection of method should be made to suit the characteristic and location of the tumour.

Fibrinolytic parameters in women undergoing ovulation induction

OBJECTIVE

The purpose of this study was to evaluate the effect of elevated levels of circulating estradiol on the clotting and fibrinolytic system in patients undergoing controlled ovarian hyperstimulation.

STUDY DESIGN

Fifty-two patients undergoing controlled ovarian hyperstimulation with human menopausal gonadotropins or urofollotropin were asked to participate. Blood for hemostasis parameters was obtained on the days that patients returned for estradiol sampling. Sample days were identified as cycle days 1 to 5 (baseline), 6 to 9, and 10 to 14. Each factor was analyzed by repeated-measures analysis of variance and correlation analysis.

RESULTS

A significant decline was observed for tissue plasminogen activator antigen and plasminogen activator inhibitor type 1 activity from baseline to cycle days 10 to 14. As serum estradiol levels increased throughout each phase (maximum mean estradiol 739.8 pg/ml), a significant linear decrease was observed for both tissue plasminogen activator antigen and plasminogen activator inhibitor type 1 activity, whereas thrombin-antithrombin III complexes did not change significantly. A significant positive correlation was also observed for plasminogen activator inhibitor activity and tissue plasminogen activator antigen level over all cycle days examined.

CONCLUSION

Down-regulation of the fibrinolytic system was observed as estradiol levels increased. However, thrombin formation did not change, thus suggesting that elevated circulating estradiol alone does not predispose to a thromboembolic event.

Adenocarcinoma and Barrett's oesophagus. A clinico-pathological study

A clinico-pathological study was carried out in two series of patients in order to determine: the prevalence of adenocarcinoma in Barrett's oesophagus in patients undergoing surgical resection for columnar cancer of the oesophagus, the incidence of Barrett's oesophagus in patients with complications of gastro-oesophageal reflux, and the subsequent cancer development in 3-20 years follow-up of such patients, compared with others who had no Barrett's oesophagus. Group 1 consisted of 264 patients with adenocarcinoma of the oesophagus undergoing resection and reconstruction; 18 (6.8%) had concomitant carcinoma and Barrett's oesophagus. These were predominantly male (male/female ratio 8/1) and had worse long-term survival than the other adenocarcinomas. Group 2 consisted of 782 patients with complications of gastro-oesophageal reflux, 26 (3.3%) of whom were found to have Barrett's oesophagus. When followed up for a period of up to 20 years, 4 (15.4%) of these developed cancer in the mean period of 11.5 years (1 case per 74 person-years). This is highly significant compared with 4 others (0.5%) who developed cancer amongst the 756 remaining patients in group 2 with no Barrett's oesophagus, in the mean interval of 8 years 2 months (1 case per over 1500 person-years). Of the 18 patients with Barrett's stricture, 4 (22%) developed cancer at a mean interval of 11.5 years representing one case per 51.7 person-years indicating a higher risk of cancer development in patients with Barrett's stricture compared with other patients with complications of gastro-oesophageal reflux with/without columnar epithelial-lined oesophagus and no stricture. Anti-reflux operation has not protected our patients with Barrett's oesophagus against cancer development.

Surgical resection for stage I cancer of the oesophagus and cardia

A study was carried out to establish the long-term survival of patients with stage I carcinoma of the oesophagus and cardia, and to assess the influence of various factors on the 5-year survival rate. The study, which was partly prospective and partly retrospective, involved 60 patients with early (stage I) carcinoma of the oesophagus or cardia from a total of 811 consecutive patients with such carcinomas who were referred to one regional centre over a 15-year period, 425 of whom underwent resection. Survival at 5 years was taken as the main measure of outcome. Forty-two patients (70 per cent) were alive at 5 years. None of the factors studied (sex, age, site or histological type of tumour) had a significant effect on outcome.

Combined endoscopic laser therapy and brachytherapy for palliation of oesophageal carcinoma: a pilot study

Palliative treatment for oesophageal malignancy aims to maximise symptom relief with minimal disturbance to the patient. Twenty one patients with oesophageal carcinoma were studied prospectively to assess the combined efficacy of laser and brachytherapy in the palliation of oesophageal carcinoma, 20 were unsuitable for resectional surgery because of tumour extent and one patient underwent the treatment protocol after myocardial infarction, for symptom relief before resection. Two patients died at hospital and the remaining 19 survived from 9 to 455 days (mean 140 days). All patients tolerated the procedure well and improvement in swallowing was noted in 19 who survived the procedure--an improvement that was maintained until their death. However, five patients required oesophageal dilatation after the initial treatment. Results were not affected by the histology of the tumour. In summary, combined endoscopic laser and brachytherapy is effective palliation for oesophageal carcinoma and may be particularly appropriate in those patients with cervical and upper thoracic tumours in whom intubation may be unsatisfactory.

The relevance of the microbiological flora of the upper alimentary tract to postoperative infection in major oesophageal surgery

A prospective study to investigate the source of pathogenic organisms responsible for infective complications of patients undergoing major oesophageal surgery was undertaken in 138 consecutive patients (38 female and 100 male) with obstructive lesions of the oesophagus, aged 24 to 86 years (mean 67 years). In all patients, the upper alimentary tract (UAT) was opened as part of the surgical procedure and 20.3% had pathogens present in their sputum before surgery. On direct culture of the contents of stomach or oesophagus at operation, 61% showed pathogenic organisms. Twenty-five patients suffered from 28 infections, predominantly pleuropulmonary infection (n = 19) but also wound sepsis (n = 8) and generalised infection (n = 1). Pathogenic organisms could not be cultured from the tracheobronchial tree immediately postoperatively. There was no correlation between preoperative sputum microbiology and postoperative infection. There was, however, a definite correlation (66% of cases) between pathogens of UAT content collected at operation and those responsible for postoperative infection. We conclude that it is relevant and important to regularly obtain samples of UAT content at operation to plan antibiotic regimes.

Antibiotic prophylaxis in oesophageal surgery

A prospective randomised study to assess the efficacy of antibiotic prophylaxis in oesophageal surgery was performed, in which 226 consecutive patients (113 male and 113 female, age range 24-86 years, mean age of 65 years) were included. The study patients were in two groups: group 1, in which the upper alimentary tract was opened during surgery, and group 2, in which it was not. The group 1 patients (n = 129) were randomised to one of three antibiotic prophylaxis regimes prior to surgery. Group A patients (n = 42) were treated with cefuroxime (CFX) 1.5 g at induction of anaesthesia and then CFX 750 mg b.i.d. for 4 days. Group B patients (n = 46) were treated with CFX 1.5 g and metronidazole (MTR) 1.0 g at induction of anaesthesia, then CFX 750 mg b.i.d. and MTR 500 mg qds for 4 days. Group C (n = 41) treated with CFX 1.5 g and MTR 1.0 g at the induction of anaesthesia. Group 2 (n = 97) was divided into two groups, group D (n = 47) treated with CFX 1.5 g on induction of anaesthesia alone. Group E (n = 50) treated with CFX 1.5 g on induction of anaesthesia then CFX 750 mg bd for 2 days. We found a significantly higher incidence of infective complications in subgroup C (43.9%) and subgroup A (21.4%) compared to subgroup B (8.6%). This difference was most marked in patients undergoing oesophagectomy. We found significantly higher infection rates of infective complications in subgroup D (10.6%) as compared to subgroup E (2%).

Experience in limited lung resection with the use of laser

This presentation concerns 100 patients undergoing limited lung resection with the use of the noncontact mode of the YAG laser: 55 (Group 1) had local excision of intrapulmonary nodular lesions--the pathology of which was, primary malignant tumor (N = 22), secondary tumor (N = 15), inflammatory and benign tumors (N = 18); 45 other patients (Group 2) had wedge and segmental resection for a variety of malignant and inflammatory conditions. In Group 1 the excision was entirely by laser, but in Group 2 laser was used in conjunction with conventional surgery. There was no hospital death or postoperative complications. We conclude: a) some forms of local pulmonary excision are best carried out by laser; b) there is a greater preservation of pulmonary tissue and wider safety margin when local excision is performed using the laser.

Benign oesophageal stricture: the place of surgery in the management of elderly patients

The results of surgery for benign oesophageal stricture in 53 consecutive cases referred to a sub-regional Cardiothoracic Unit are presented. The operations included retrograde dilatation and either total fundoplication or Allison repair, or an oesophageal resection with gastro-oesophageal anastomosis through a trans-thoracic approach. Postoperative fatality was 9%. Most subsequent deaths were due to unrelated acute events with a 5-year survival rate of 62%. Sixty per cent were free from dysphagia and 82% led active and independent lives without support. Surgery offers an alternative to dilatation in elderly patients with oesophageal stricture.

Relevance of anatomopathology of high oesophageal strictures to the design of surgical treatment

From 1971-1987, inclusive, 407 patients with oesophageal stricture were operated on by one surgeon. Of these, 116 were found to have high oesophageal stricture and form the basis of this presentation. Every patient had the usual clinical, radiological and endoscopic examinations with biopsies taken above, at, and (when possible) below the stricture. At operation, the surgical anatomy and pathology of the oesophagus and mediastinum were determined and the site of the peritoneal reflexion and its relation to the stricture were noted. In those resected, the resected specimen was examined histopathologically. Thus clear aetiopathology could be established and this was correlated with the type of operation. Postoperatively, patients were followed up regularly. Results showed that high strictures were of four definite types: (1) reflux strictures with short oesophagus (n = 90) of whom 52% required resection and 48% had conservative surgery, (2) caustic and other non-reflux strictures (n = 10) all of whom required resection, (3) Barrett-type strictures (n = 8) all treated by conservative surgery, (4) idiopathic strictures (n = 8) of whom half required resection because of suspicion of malignancy. The study indicated that the rational basis for the design of surgery is to ascertain the aetiopathology which can only and finally be determined at operation.

Chemotherapy-induced premature ovarian failure: mechanisms and prevention

Significant advances have been made in the previously unexplored areas of the mechanisms involved in cyclophosphamide (CTX)-induced ovarian toxicity and the protective effects of luteinizing hormone-releasing hormone (LHRH agonists. The structure and function of granulosa cells and oocytes are affected by the chemotherapeutic agent, CTX. Results of experiments in female rats indicate that LHRH agonists may protect the ovaries from the toxic effects of chemotherapy. The protective effect may be related to the inhibition of ovarian mitotic activity during LHRH agonist administration. This inhibition is much more pronounced in female compared to male rats. This may be related to the observed better gonadal protective effects in females compared to males. Further experiments are underway to determine whether similar protective effects occur in female primates.